Optimal management of large endometriomas (≥ 4 cm) before IVF: ethanol sclerotherapy, cystectomy, or no intervention?

Between January 2020 and December 2023, 176 patients with endometriomas underwent their first IVF cycle. Among them, 107 patients with at least one endometrioma measuring ≥ 4 cm were assessed for eligibility. After applying the inclusion and exclusion criteria, 90 patients were included in the final analysis: 39 patients underwent IVF with endometriomas in situ, 20 patients underwent IVF following EST procedure, and 31 patients underwent IVF following laparoscopic cystectomy (Fig. 1 ). The demographic characteristics of the groups, including age, BMI, duration of infertility, number of previous IVF cycles, and history of prior endometriosis surgery were comparable. Serum AMH levels at presentation, when IVF was planned, did not differ significantly between groups (Table 1 ). However, the largest endometrioma was significantly smaller in the OMA in situ group compared to the EST and Cystectomy groups ( P  < 0.001). Additionally, the number of endometriomas and the bilaterality rate were significantly higher in the EST group compared to the OMA in situ and Cystectomy groups ( P  = 0.001 and P  = 0.004, respectively) (Table 1 ). Fig. 1 Flow chart of the study population Flow chart of the study population Table 1 Comparison of the demographic characteristics between the study groups OMA in situ N  = 39 EST N  = 20 Cystectomy N  = 31 P value Age, years 33±5.5 32.5±4.1 31.6±5.2 0.499 BMI, kg/m 2 23.1±4 25.5±4.1 23.2±3.3 0.054 Duration of infertility, years 3.6±2.5 4.8±2.8 4.4±2.8 0.190 No. of previous pregnancies 0.3±0.6 0.2±0.6 0.3±0.6 0.882 No. of previous IVF cycles 0.6±0.8 0.3±0.7 0.8±0.9 0.112 Previous endometriosis surgery, n (%) 2 (5.1) 2 (10) 5 (16.1) 0.313 Baseline serum AMH level, ng/ml 2.1±1.3 2.6±1.5 1.9±0.9 0.219 Largest OMA size, cm 4.5±0.9 6±1.7 5.6±1.3 < 0.001 a Total no. of OMA’s 1.6±0.7 2.5±1.3 1.7±0.8 0.001 b Bilateral OMA, n (%) 10 (25.6) 14 (70) 15 (48.4) 0.004 EST ethanol sclerotherapy, BMI body mass index, IVF in vitro fertilization, OMA endometrioma a The statistical significance stems from the differences between groups A vs. B ( P  < 0.001) and A vs. C ( P  = 0.001) b The statistical significance stems from the differences between groups A vs. B ( P  = 0.001) and B vs. C ( P  = 0.008) Comparison of the demographic characteristics between the study groups EST ethanol sclerotherapy, BMI body mass index, IVF in vitro fertilization, OMA endometrioma a The statistical significance stems from the differences between groups A vs. B ( P  < 0.001) and A vs. C ( P  = 0.001) b The statistical significance stems from the differences between groups A vs. B ( P  = 0.001) and B vs. C ( P  = 0.008) The comparison of IVF cycle characteristics between the groups is summarized in Table 2 . All parameters, except baseline AFC, and serum estradiol level on the day of trigger, were comparable among the groups. The baseline AFC was significantly higher in the EST group compared to both the OMA in situ and Cystectomy groups (10.7 ± 5.4 vs. 6.5 ± 3.6 vs. 5.4 ± 2.9, respectively; P  < 0.001). In the EST group, the serum preoperative and postoperative AMH levels were 2.6 ± 1.5 ng/ml and 2.3 ± 1.5 ng/ml, respectively ( P  = 0.576). In contrast, in the Cystectomy group, the serum preoperative and postoperative AMH levels were 1.9 ± 0.9 ng/ml and 0.9 ± 0.6 ng/ml, respectively ( P  = 0.001). Table 2 Comparison of ovarian stimulation cycle parameters between the study groups OMA in situ N =39 EST N =20 Cystectomy N =31 P value Baseline FSH, IU/l 9.2±3 9.1±4.6 10±5.5 0.744 Baseline LH, IU/l 5.7±2.1 6.9±3.7 5.4±3.2 0.259 Baseline estradiol, pg/ml 53.1±29.8 45±10.9 52±38 0.631 Baseline progesterone, ng/ml 0.6±0.3 0.4±0.2 0.6±0.3 0.144 Baseline antral follicle count 6.5±3.6 10.7±5.4 5.4±2.9 <0.001 a Gonadotropin starting dose, IU 277±50 255±38 270±63 0.448 Duration of stimulation, days 10.1±1.6 10.7±1.6 9.8±2.3 0.240 Total gonadotropin dose, IU 2701±683 2558±679 2678±1117 0.769 Estradiol on the DoT, pg/ml 1803±1241 2017±703 1246±913 0.033 b Progesterone on the DoT, ng/ml 0.9±0.5 1±0.6 1±0.5 0.440 LH on the DoT, IU/l 3.8±3.1 4.1±4.9 5.8±8 0.346 Type of trigger, n (%) 0.544 GnRH agonist 3 (7.7) 4 (20) 2 (6.5) Recombinant hCG 27 (69.2) 12 (60) 23 (74.2) Dual 9 (23.1) 4 (20) 6 (19.4) EST ethanol sclerotherapy, FSH follicle stimulating hormone, LH luteinizing hormone, OMA endometrioma, DoT day of trigger a The statistical significance stems from the differences between groups A vs. B ( P =0.001), and B vs. C ( P <0.001) b The statistical significance stems from the difference between groups B vs. C ( P =0.043) Comparison of ovarian stimulation cycle parameters between the study groups EST ethanol sclerotherapy, FSH follicle stimulating hormone, LH luteinizing hormone, OMA endometrioma, DoT day of trigger a The statistical significance stems from the differences between groups A vs. B ( P =0.001), and B vs. C ( P <0.001) b The statistical significance stems from the difference between groups B vs. C ( P =0.043) Table 3 summarizes the comparison of outcome parameters among the groups (Endometrioma in situ, EST, and Cystectomy). The numbers of total oocytes retrieved were 7.4 ± 5.3, 12.6 ± 4.6, and 5.1 ± 3.6, respectively, and the numbers of MII oocytes were 5.7 ± 4.3, 10.1 ± 3.9, and 4.2 ± 3.5, respectively, with both being significantly higher in the EST group ( P  < 0.001). Fertilization rates were similar across groups; however, the numbers of total embryos (2.6 ± 2.7, 3.9 ± 2.5, and 1.4 ± 1.7) and good-quality embryos (2.1 ± 2.1, 2.8 ± 2.1, and 1.3 ± 1.3) were significantly higher in the EST group compared with the Cystectomy group ( P  = 0.001 and P  = 0.020, respectively). The cycle cancellation rates differed significantly among the groups, with the highest rate observed in the Cystectomy group (12.8% vs. 10% vs. 35.5%; P  = 0.028). Both implantation rates and pregnancy rates per ET were comparable across the groups. However, the pregnancy rate following fresh ET was significantly lower in the OMA in situ group compared to the other groups ( P  = 0.044). The cumulative CPR’s were 33.3% in the OMA in situ group, 65% in the EST group, and 32.3% in the Cystectomy group ( P  = 0.035). Similarly, the CLBR’s were 30.8% in the OMA in situ group, 65% in the EST group, and 29% in the Cystectomy group ( P  = 0.017). Table 3 Comparison of in vitro fertilization cycle outcome parameters OMA in situ N  = 39 EST N  = 20 Cystectomy N  = 31 P value No. of oocytes collected 7.4±5.3 12.6±4.6 5.1±3.6 < 0.001 a No. of MII oocytes collected 5.7±4.3 10.1±3.9 4.2±3.5 < 0.001 b Fertilization rate, % 71.1±26.9 58.4±19.9 63±27.9 0.205 Total no. of embryos 2.6±2.7 3.9±2.5 1.4±1.7 0.001 c No. of grade 1–2 embryos 2.1±2.1 2.8±2.1 1.3±1.3 0.020 d Cycle cancellation, n (%) 5 (12.8) 2 (10) 11 (35.5) 0.028 Implantation rate, % 21.7±36 41.7±30.9 34.6±39.4 0.102 Pregnancy per ET, n (%) 14 (30.4) 13 (59.1) 13 (50) 0.055 Pregnancy per fresh ET, n (%) 11 (32.4%) 11 (66.7%) 11 (55) 0.044 Cumulative CPR, n (%) 13 (33.3) 13 (65) 10 (32.3) 0.035 Cumulative LBR, n (%) 12 (30.8) 13 (65) 9 (29) 0.017 EST ethanol sclerotherapy, OMA endometrioma, ET embryo transfer, CPR clinical pregnancy rate, LBR live birth rate a The statistical significance stems from the differences between groups A vs. B ( P  < 0.001) and B vs. C ( P  < 0.001) b The statistical significance stems from the differences between groups A vs. B ( P  < 0.001) and B vs. C ( P  < 0.001) c The statistical significance stems from the difference between groups B vs. C ( P  = 0.001) d The statistical significance stems from the difference between groups B vs. C ( P  = 0.017) Comparison of in vitro fertilization cycle outcome parameters EST ethanol sclerotherapy, OMA endometrioma, ET embryo transfer, CPR clinical pregnancy rate, LBR live birth rate a The statistical significance stems from the differences between groups A vs. B ( P  < 0.001) and B vs. C ( P  < 0.001) b The statistical significance stems from the differences between groups A vs. B ( P  < 0.001) and B vs. C ( P  < 0.001) c The statistical significance stems from the difference between groups B vs. C ( P  = 0.001) d The statistical significance stems from the difference between groups B vs. C ( P  = 0.017) No major complications were observed following the EST procedures. One patient was hospitalized one day after the procedure due to mild fever and was treated with intravenous antibiotics. Another patient experienced moderate pelvic pain six hours post-procedure, which was managed with intravenous hydration and analgesics. There were no recurrences observed at the time of the IVF procedures. All laparoscopic cystectomies were completed successfully without conversion to laparotomy or major/minor complications, and all patients were discharged on postoperative day 1.

This single-center retrospective cohort study reviewed data from infertile women with at least one endometrioma ≥ 4 cm who underwent intracytoplasmic sperm injection following a GnRH antagonist cycle at the Infertility Centre, Ankara University Cebeci Hospital, between January 2020 and December 2023. The study protocol was approved by the Institutional Review Board of Ankara University School of Medicine (i01-85-25, 02.17.2025). Patients in the control group underwent IVF with the endometrioma in situ (OMA in situ). Patients in the first study group underwent IVF following ethanol sclerotherapy for endometrioma/s (EST), while those in the second study group underwent IVF following laparoscopic endometrioma cystectomy (Cystectomy). The choice of management strategy for each patient was made at the discretion of the primary physician. Only the first fresh IVF cycle for each patient, along with the frozen-thawed embryo transfer (FET) cycles performed using embryos obtained from that cycle, were included in the study. Data related to both fresh IVF and FET cycles were extracted from patient files and the hospital database. The inclusion criteria were: female age 20–40 years, a GnRH antagonist cycle, and utilization of all available embryos. The exclusion criteria included: utilization of long or natural cycle protocols, progestin-primed ovarian stimulation, presence of adenomyosis, untreated hydrosalpinx, untreated thyroid dysfunction or hyperprolactinemia, and severe male factor infertility, and an interval of more than 12 months since cystectomy. The 12-month limit was chosen because patients’ return after surgery can sometimes be delayed, and beyond this period the potential beneficial effects of cystectomy may diminish, endometriosis may recur, and, in order to minimize the potential impact of the natural decline in ovarian reserve on the outcomes, these patients were excluded. All patients underwent transvaginal ultrasound-guided aspiration of one or more endometriomas, as previously described in detail [ 24 ]. The procedure was performed by an experienced reproductive surgeon (YEŞ) with the patient in the lithotomy position under sedation or local anesthesia. To prevent pelvic infections, prophylactic antibiotics were administered, consisting of 2 g of cefazolin administered intravenously during the procedure, followed by oral doxycycline twice daily for one week. The size, number, and laterality of the endometriomas were recorded prior to the procedure. Using ultrasound guidance, a single-lumen 16G needle was employed to puncture the cyst transvaginally. The cyst contents were fully aspirated, and the aspirated volume was documented. The first sample of the aspirated cyst fluid was sent for cytological analysis. The cyst cavity was then flushed with saline solution until the aspirated fluid became clear. If aspiration was challenging due to thick content, flushing with small volumes of saline was initiated earlier. Following this, 96.5% ethanol was injected into the cyst cavity at 60% of the aspirated volume to avoid overdistension, rupture, or leakage. If the cyst ruptured during aspiration or flushing, the procedure was abandoned. If ethanol leakage into the pelvis was suspected, ethanol injection was immediately discontinued, and the leaked ethanol was aspirated from the Douglas pouch. The ethanol was left in the cyst for 10 min before being completely aspirated, and the final volume was recorded. In cases where ethanol loss exceeded 5 mL, patients were monitored in the hospital for at least six hours. As per our clinical protocol, EST patients were scheduled for IVF within 3 months to ensure complete resolution and minimize the risk of recurrence. All cystectomies were performed by experienced reproductive surgeons under general anesthesia using a standard laparoscopy technique. After inspection of the pelvic cavity, endometriomas were identified and carefully incised. The cyst wall was stripped from the normal ovarian cortex by traction and counter-traction, aiming to preserve healthy ovarian tissue. Hemostasis was achieved using bipolar cautery with minimal thermal damage, and copious irrigation was applied. The excised cyst wall was retrieved for histopathological examination. Before the initiation of treatment, all patients underwent a transvaginal ultrasound on day 2 of their menstrual cycle, and baseline hormonal profiles were assessed. Ovarian stimulation was carried out using recombinant FSH (Gonal-F; Merck-Serono, Geneva, Switzerland) and/or human menopausal gonadotropin (hMG; Menopur; Ferring GmbH, Wittland, Kiel, Germany), starting on the second day of the menstrual cycle at an initial dose of 225–300 IU/day. The dose was adjusted individually based on ovarian response, as assessed by estradiol levels and ultrasound. The GnRH antagonist cetrorelix 0.25 mg/day (Cetrotide; Merck-Serono, Geneva, Switzerland) was initiated on a fixed schedule starting on the sixth day of stimulation and continued throughout the stimulation period. The final oocyte maturation trigger was administered when at least one follicle reached a diameter of ≥ 18 mm or at least two follicles measured ≥ 17 mm, using one of the following regimens: 250 µg of choriogonadotropin alpha (hCG trigger) (Ovitrelle, Merck-Serono, Bari, Italy), 0.2 mg of triptorelin acetate (GnRH agonist trigger) (Gonapeptyl; Ferring GmbH, Kiel, Germany), or 250 µg of choriogonadotropin alpha combined with 0.2 mg of triptorelin acetate (dual trigger). Transvaginal ultrasound-guided oocyte pick-up (OPU) with a double-lumen needle was performed 36 h after the trigger. Standard intracytoplasmic sperm injection (ICSI) was conducted on metaphase II (MII) oocytes. The criteria for embryo grading were previously described elsewhere [ 25 ]. Briefly, embryos were classified as top quality when they had four or five blastomeres on day 2, at least seven blastomeres on day 3, absence of multinucleated blastomeres, and less than 10% fragmentation at the cleavage stage [ 26 ]. Blastocyst-stage embryos were graded based on Gardner and Schoolcraft’s criteria, which evaluate the developmental stage of the embryo as well as the morphology of the trophoblast and inner cell mass [ 27 ]. Top-quality blastocysts were graded as AA, AB, BA, or BB. In the present study, none of the embryos underwent preimplantation genetic testing for aneuploidies. Embryo transfer (ET) was performed using soft embryo catheters under transabdominal ultrasound guidance. A maximum of two embryos were transferred in accordance with national regulations on embryo transfer policy. In fresh ET cycles, luteal phase support was initiated on the day of oocyte retrieval with 600 mg/day of vaginal progesterone (Progestan, 200 mg vaginal capsules; Koçak Farma, Tekirdağ, Türkiye) and continued until the 10th week of gestation for women who achieved clinical pregnancy. In FET cycles, luteal phase support was administered with 800 mg/day of vaginal progesterone (Progestan 200 mg vaginal tablets; Koçak Farma, Tekirdağ, Türkiye) ± daily subcutaneous progesterone (Progestan dex 25 mg; Koçak Farma, Tekirdağ, Türkiye). The primary outcome measure was the cumulative live birth rate per initiated IVF cycle. The cumulative live birth rate was defined as the number of deliveries with at least one live birth resulting from one initiated IVF cycle, including all cycles in which fresh and/or frozen embryos are transferred, until one delivery with a live birth occurs or until all embryos are used, whichever occurs first [ 28 ]. Live birth was defined by a live birth after 22 weeks of gestation [ 28 ]. The secondary outcome measures were the number of mature oocytes collected, fertilization rate, number of top-quality embryos, implantation rate (number of intrauterine gestational sacs divided by the number of transferred embryos), clinical pregnancy rates, and cycle cancellation rate. Clinical pregnancy was defined as the visualization of fetal heartbeat on ultrasound at 7 weeks. Data analyses were performed by using SPSS Version 21.0 (IBM Corporation, Armonk, NYC, USA). Samples were tested with the Shapiro-Wilk test to determine normality of distributions. According to the results, parametric tests were preferred. Continuous variables are presented as mean±standard deviation, and categorical variables are presented as frequency (percentage). Continuous variables were compared with one-way ANOVA test. Categorical variables were compared with the chi-square test or Fisher’s exact test where appropriate. A P value of < 0.05 was considered statistically significant. When there is a statistically significant difference, a post hoc analysis was performed in between all group pairs to define the source of statistical significance.

The present study was conducted to compare the cumulative outcomes of the first IVF cycle in patients with endometriomas ≥ 4 cm, either with OMA in situ, following EST, or following laparoscopic cystectomy. According to the results of our study, the EST group yielded significantly higher numbers of oocytes, MII oocytes, and good-quality embryos compared to the other two groups. Consequently, the CLBR was also higher in the EST group. However, fertilization and implantation rates were similar across all groups. In the cystectomy group, the higher cycle cancellation rate was a notable finding. Previous studies on EST have shown considerable variability in technique, patient selection criteria, and follow-up duration, all of which may influence recurrence rates and IVF outcomes [ 29 ]. However, previous studies comparing IVF outcomes between EST and direct IVF have consistently reported approximately twice the CPR or LBR in the EST group [ 20 – 22 ]. However, none of these studies assessed cumulative success rates. Unlike our study, they found similar numbers of retrieved oocytes across groups [ 20 – 22 ]. This discrepancy may stem from their inclusion of patients with smaller or unilateral endometriomas, whereas our study specifically focused on patients with larger endometriomas (≥ 4 cm), likely contributing to the higher number of retrieved oocytes and embryos in the EST group. Comparative studies on EST and cystectomy before IVF have reported either similar or superior outcomes for EST [ 17 – 19 , 23 ]. Two studies, consistent with our findings, observed a higher oocyte yield in the EST group [ 19 , 23 ]. A very recent meta-analysis by Lavadia et al. reported that EST was associated with higher numbers of total and MII oocytes, greater embryo yield, and increased clinical pregnancy rates compared with cystectomy [ 30 ]. As shown in numerous previous studies, our results confirm that, unlike cystectomy, EST does not negatively impact ovarian reserve [ 17 , 18 , 31 – 34 ]. Taken together, these findings suggest that EST provides a quantitative advantage in IVF outcomes compared to both cystectomy and no intervention. According to our study, EST has no impact on oocyte quality. Indirect markers, such as fertilization and high-quality embryo rates, were comparable between the groups. Previous studies have also reported similar fertilization rates when comparing EST with both OMA in situ and cystectomy groups [ 11 , 17 , 18 , 20 , 21 ]. Only Aflatoonian et al. assessed top-quality embryo rates, finding a significantly higher rate with EST compared to OMA in situ [ 22 ]. Furthermore, we did not observe a statistically significant positive effect of EST on implantation rates. Similarly, three other comparative studies assessed implantation rates but failed to demonstrate a beneficial effect [ 18 , 20 , 23 ]. Our study’s most significant finding is the higher CLBR in the EST group, likely due to the increased number of retrieved oocytes and embryos. Another key result is the higher success rate of fresh ET in both the EST and cystectomy groups compared to the OMA in situ group. This may be explained by reduced inflammation following these procedures, as endometriosis is known to induce inflammation and angiogenesis in the uterine environment, potentially affecting endometrial receptivity [ 35 , 36 ]. Although they did not demonstrate a quantitative benefit, in line with our findings, Rabattu et al. also suggested that the increased CPR associated with EST may be attributed to reduced inflammation, which could improve implantation and oocyte quality [ 21 ]. Moreover, supraphysiologic steroid hormone levels during ovarian stimulation may negatively impact endometrial receptivity [ 35 , 37 , 38 ]. A recent meta-analysis also found that frozen-thawed ET leads to better reproductive outcomes than fresh ET in patients with endometriosis [ 39 ]. The main strength of our study is the direct comparison of three management approaches for large endometriomas before IVF, with CLBR as the primary outcome, providing a comprehensive evaluation of treatment success. The inclusion of a well-defined cohort and standardized IVF protocols enhances internal validity. Additionally, restricting the study to patients undergoing their first IVF cycle and using an accurate definition of CLBR, along with assessing both quantitative and qualitative markers, further strengthens its findings. However, the retrospective design introduces potential selection bias, and the relatively small sample size and the absence of sample size calculation limits generalizability. Moreover, the imbalance in endometrioma size and number between the groups is another limitation. However, including patients with larger and multiple endometriomas in the EST group reinforces the robustness of the findings. Another limitation of the study was that the choice of management strategy was left to the discretion of the primary physician, which might have been influenced by several factors such as endometriosis severity, symptoms, previous surgical history, and physician experience. Although no physician adhered exclusively to a specific treatment option, in selected patients this may have affected the outcomes. However, given the retrospective design, we were not able to assess these specific factors at the decision-making step, and we had no opportunity to assign patients to treatment groups; instead, we compared IVF outcomes, which were performed in a standardized manner for all patients. In conclusion, EST before IVF significantly improves CLBR compared to both no intervention and cystectomy in patients with endometriomas ≥ 4 cm. Ethanol sclerotherapy prior to IVF was associated with a higher oocyte and embryo yield and lower cycle cancellation rates without compromising ovarian reserve. These findings suggest that EST may be a preferred approach for optimizing IVF outcomes in infertile patients with large endometriomas. Further prospective studies with larger sample sizes are warranted to confirm these results and assess long-term ovarian function post-EST.

Endometriosis is a chronic, estrogen-dependent inflammatory disease characterized by the presence of endometrial tissue outside the uterus. The main clinical manifestations are pain and infertility [ 1 ]. While the link between endometriosis and infertility is well established, the underlying mechanisms are complex and multifactorial including anatomical alterations in the pelvic cavity, impaired folliculogenesis, granulosa cell dysfunction, immune dysregulation, and defects in fertilization or implantation [ 2 ]. Evidence from assisted reproductive technology (ART) studies suggests that endometriosis may also impair oocyte quality through disruptions in steroid metabolism, oxidative stress responses, and cell cycle regulation [ 3 , 4 ]. Abnormal inflammation, local estrogen production, and progesterone resistance further contribute to reduced endometrial receptivity [ 5 , 6 ]. Endometriomas can potentially impact IVF outcomes in three keyways: reducing the number of retrievable oocytes, impairing oocyte quality, and decreasing implantation chances. The presence of endometriomas has been linked to reduction in ovarian reserve, likely due to the chronic inflammatory environment they create [ 7 ]. Additionally, large endometriomas may limit follicular access during IVF, reducing the number of oocytes retrieved and consequently affecting cumulative outcomes, even if per-embryo transfer success rates remain unchanged [ 8 – 10 ]. Two recent meta-analyses by Gayete-Lafuente et al. and Alshehre et al. evaluated the impact of presence of endometriomas on IVF outcomes and reported similar live birth rates between patients with and without endometriomas [ 8 , 9 ]. However, their analyses were conducted per cycle rather than cumulatively. Given the observed reduction in the number of oocytes retrieved and good quality embryos, cumulative live birth rates could potentially be diminish. While some studies suggest that endometriomas negatively influence oocyte and embryo quality, two recent meta-analyses indicate no significant impact [ 8 , 9 ]. To assess their effect on implantation rates, donor oocyte cycles provide the most reliable evidence. A recent meta-analysis suggests a slight negative effect of endometriomas on implantation, though this remains inconclusive [ 11 ]. In infertile women with endometriomas scheduled for IVF, laparoscopic cystectomy is recommended if the patient experiences pain or if the endometrioma is expected to complicate oocyte retrieval [ 10 ]. If endometriomas negatively impact oocyte and embryo quality or implantation, surgery could potentially improve outcomes. However, laparoscopic cystectomy is known to significantly reduce ovarian reserve [ 12 ]. While studies suggest that IVF success rates per embryo transfer or cycle may remain unchanged post-surgery, most available data do not focus on cumulative outcomes [ 13 ]. Additionally, although surgery may not alter overall outcomes in the general IVF population, it increases cycle cancellation rates, which could have a particularly detrimental impact on certain patients [ 14 ]. Ethanol sclerotherapy (EST), though an established technique for managing endometriomas, has recently gained renewed attention and is increasingly preferred as a preliminary procedure for patients planning IVF [ 15 – 21 ]. Recent studies suggest that IVF outcomes are improved in patients undergoing EST prior to IVF compared to those who do not [ 20 – 22 ]. Furthermore, comparisons between EST and cystectomy before IVF have shown similar or more favorable results for EST [ 17 – 19 , 23 ]. However, existing studies have not adequately assessed cumulative success rates. Briefly, the presence of endometriomas during IVF may reduce the number of oocytes retrieved, leading to fewer embryos for transfer and lower cumulative live birth rates. Laparoscopic cystectomy may improve oocyte quality and implantation, but it also significantly reduces ovarian reserve, potentially further lowering cumulative outcomes. Ethanol sclerotherapy (EST) offers an alternative approach, eliminating endometriomas while better preserving ovarian reserve. This study aims to compare the cumulative live birth rates (CLBR) among three primary approaches for patients with large endometriomas undergoing IVF: IVF with the endometrioma left in situ, IVF after EST, and IVF following laparoscopic cystectomy.